Cold Sore

Cold sore

Definition

Cold sores are small red blisters, filled with clear fluid, that form on the lip and around the mouth. Rarely, they form on the roof of the mouth. Cold sores are caused by the herpes simplex virus type 1 (HSV-1), which lives inside nerve tissue. Despite their name, cold sores have nothing to do with colds. The herpes simplex virus type 1 should not be confused with the herpes simplex virus type 2 (HSV-2), which most often causes genital herpes.

Description

There are eight different kinds of human herpes viruses. Only two of these, herpes simplex types 1 and 2, can cause cold sores. It is commonly believed that herpes simplex virus type 1 infects above the waist and herpes simplex virus type 2 infects below the waist. This is not true. Both herpes virus type 1 and type 2 can cause herpes lesions on the lips or genitals, but recurrent cold sores are almost always type 1.

The sores can appear within days or weeks or even years following the first exposure to the virus. The first time symptoms appear they are usually more intense than later outbreaks. For example, some children experience more pain at the blister site or even flu-like symptoms, including swollen glands, fever , or sore throat . Medical names for cold sores include oral herpes, labial herpes, herpes labialis, and herpes febrilis.

Transmission

Herpes simplex virus is transmitted by infected body fluids (such as saliva) when they contact breaks in another person's skin or mucous membranes. Newborns may become infected during delivery through an infected birth canal. HSV-1 can be passed to children by parents, nurses, and caregivers who fail to practice careful hand washing. Children with burns , eczema, or diaper rash or those who are immunosuppressed are highly susceptible to the herpes virus.

VIRUS VERSUS BACTERIA Viruses behave differently than bacteria. While bacteria are independent and can reproduce on their own, viruses enter human cells and force them to make more viruses. The infected human cell dies and releases thousands of new viruses. The cell death and resulting tissue damage causes the cold sores. In addition, the herpes virus can infect a cell, and instead of making the cell produce new viruses, it hides inside the cell and waits. The herpes virus hides in the nervous system. This action is called latency. A latent
virus can wait inside the nervous system for days, months, or even years. At some future time, the virus "awakens" and causes the cell to produce thousands of new viruses that cause an active infection.

Latent and active infection is understood by considering the cold sore cycle. The first infection is the primary infection. The primary infection is controlled by the body's immune system and the sores heal. Between active infections, the virus is latent. At some point in the future, latent viruses become activated and once again cause sores or recurrent infections. Although it is unknown what triggers latent virus to activate, several conditions bring on infections. These include stress, illness, fever, fatigue, exposure to sunlight, menstruation , and diet.

Demographics

The herpes simplex virus is widespread in children. Thirty-five percent of five-year olds carry HSV-1 antibodies. A primary infection commonly occurs by the time a child reaches age five. These viral infections are more common in lower socioeconomic groups.

Nearly 80 percent of the general population carry the herpes simplex virus that causes cold sores, and 60 million have outbreaks once or more in a year. Most infants and children harbor the herpes virus before age ten. Interestingly enough, only 20 percent to 25 percent of those carrying the virus ever gets symptoms (break out in cold sores).

Causes and symptoms

While anyone can have the herpes virus infection, not everyone will show symptoms. The first symptoms of herpes occur within two to 20 days after contact with an infected person. Symptoms of the primary infection are usually more severe than those of recurrent infections. The primary infection can cause symptoms like other viral infections, including fatigue, headache , fever, and swollen lymph nodes in the neck.

Typically, 50 to 80 percent of children with oral herpes experience a prodrome (symptoms of oncoming disease) of pain, burning, itching , or tingling at the site where blisters will form. This prodrome stage may last a few hours or one to two days. The herpes infection prodrome occurs in both the primary infection and recurrent infections.

In 95 percent of the patients with cold sores, the blisters occur at the outer edge of the lips, which is called the vermillion border. Less often, blisters form on the nose, chin, or cheek. Following the prodrome, the disease process is rapid. First, small red bumps appear. These quickly form fluid-filled blisters.

Causes of cold sores in children

Infants are most likely to get a cold sore because someone with an active virus kisses them. The cause can even be a kiss from someone who did not have a visible sore but had the virus in his or her saliva. A baby may also get the herpes virus passing through the birth canal if the mother has genital herpes.

Once a child gets the virus, it stays in his body permanently, hiding in nerve cells near the ear. In some children, the virus lies dormant and never causes harm. In others, it periodically wakes up and triggers cold sores. Nobody knows what stirs the virus into action, but stress, fever, colds, and sunburn encourage outbreaks. Rich foods such as chocolate, food allergies , or hormonal changes may also cause outbreaks in children and adolescents.

Symptoms of cold sores in infants

The first symptoms of cold sores in infants are swollen gums and sore mouth. A few days later, there is a cluster of small blisters on or near the lips that turn into a shallow, painful sore. The breakout is often accompanied with fever and swollen lymph glands in the neck. In a few days the sore will crust and slowly disappear. The whole flare-up lasts about seven to ten days. The next time the infant has an outbreak the blister is the first symptom, not the swollen gums and painful mouth. If not treated, recurring outbreaks may last longer.

Stages of cold sores in children and adolescents

Cold sores, untreated, can last up to 14 days. Children often feel the tingling at the site before the sore appears. Parents should begin the treatment at the first sign of tingling or redness, which can reduce the time to two to four days. Beginning treatment after the blister appears can also significantly reduce the time and degree of pain. The following describes the stages of a cold sore:

Day 1: Prodrome (tingle) stage: Before a blister appears, the child usually feels a tingling, itching, or burning sensation beneath the skin, usually around the mouth or the base of the nose. This is the best time to start treatment.

Days 2 to 3: The blister or blisters appear. Children usually have one or several blisters on or around the moth, most often at the border of the lip and the skin on the face. Cold sores occasionally occur on the roof of the mouth.

Day 4: Ulcer or weeping stage: The blister opens, revealing a reddish area. The child is most contagious and in the most pain at this point.

Days 5 to 8: Crusting stage: The blisters dry up, and a crust forms which is yellow or brown in color. Children should be told not to pick at this crust.

Days 9 to 14: Healing stage: A series of scabs form over the sore, each smaller than the previous one until the cold sore is healed.

When to call the doctor

The HSV-1 virus can cause ocular herpes, a serious eye infection affecting the cornea (the clear window) of the eye, which can threaten vision and needs immediate medical attention and treatment. When a baby or child has a cold sore, parents should do all they can to keep them from touching their eyes. If a painful sore appears on the child's eyelid, eye surface, or on the end of his nose, call the pediatrician right away. The child may need antiviral drugs to keep the infection from scarring the cornea. Ocular herpes can weaken vision and even cause blindness.

Some children have a serious primary (first episode) herpes infection called gingivostomatitis, which causes fever, swollen lymph glands, and several blisters inside the mouth and on the lips and tongue that may form large, open sores. These painful sores may last up to three weeks and can make eating and drinking difficult. Because of this problem, young children with gingivostomatitis are at risk for dehydration . Children with this condition should be seen by a doctor.

Most infants have protection for at least six months from HSV-1 by antibodies they received from their mothers. But if a newborn gets a cold sore, the pediatrician should be called right away.

If the immune system of children is compromised because of cancer treatment or AIDS , they could have more serious problems with the herpes virus. Parents should let the doctor know if these health conditions exist.

Children with a history of frequent herpes flare-ups who spend time skiing or on the beach should call a doctor for a prescription for starting oral anti-herpes medication (pills) before such outings and then using sunscreen while they are outside. These precautions can prevent most outbreaks.

Diagnosis

Cold sores are diagnosed by review of symptoms, physical examination, and history. The diagnosis is confirmed by various viral tests. A Tzanck or Papanicolau smear may be done. A positive smear cannot distinguish between varicella zoster virus and HSV-1, and a negative smear does not rule out HSV infection. Tissue culture provides a more reliable method of diagnosis. Cells killed by the herpes virus have a certain appearance under the microscope. Laboratory blood test looks for the virus or to confirm the presence of antibodies that fight the virus.

Approximately 85 percent of active herpes infections are without symptoms. When the symptoms do appear, they have the following sequence:

burning, itching, or tingling at the site before the sore appears

clusters of fluid-filled vesicles ulcerate, dry, and crust

lesions dry and crust within seven to ten days

usually one or two lesions present on the lips, tongue, gingival, or buccal mucosa

puritis (itching) and pain

Treatment

There is no cure for herpes virus infections. Antiviral drugs are available that have some effect on lessening the symptoms and decreasing the length of herpes outbreaks. There is evidence that some may also prevent future outbreaks. These antiviral drugs work by interfering with the reproduction of the viruses and are most effective when taken as early in the infection as possible. For the best results, drug treatment should begin during the prodrome stage before blisters are visible. Depending on the length of the outbreak, drug treatment could continue for up to ten days.

Antiviral pills such as acyclovir (Zovirax), famciclovir, (Famvir), and valacyclovir (Valtrex) can cancel an outbreak and help prevent recurrent outbreaks. Acyclovir (Zovirax) is the drug of choice for herpes infection and can be given intravenously or taken by mouth. A liquid form for children is also available. Acyclovir is effective in treating both the primary infection and recurrent outbreaks. When taken by mouth, acyclovir reduces the frequency of herpes outbreaks.

Antiviral creams Zovirax and Denavir should be applied within the first 24 hours of feeling the tingling or discomfort, before the plaster erupts. The duration of the outbreak can be shortened by a day or two. Antiviral creams are not as effective as the pills.

During an outbreak, sores should be washed once or twice a day with warm, soapy water, and gently patted dry. Over-the-counter lip products that contain the chemical phenol (such as Blistex Medicated Lip Ointment) and numbing ointments (Anbesol) help to relieve cold sores. A bandage over the sores protects them and prevents spreading the virus to other sites on the lips or face.

Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) may be necessary to reduce pain and fever.

Alternative treatment

Cold sores in infants and children will go away on their own, but there are measures that will help the child feel better:

To ease the pain, apply ice to the sore, or if the doctor approves, give the baby a mild pain reliever, such as ibuprofen or acetaminophen. (Do not give aspirin to a baby; it could trigger Reye's syndrome. This is a rare but potentially life-threatening illness.) Choices for pain relief include medication, ointments, or mouth rinses recommended by the pediatrician. Parents may also use Oragel, an ointment often used for canker sores or teething.

Avoid giving the child spicy, salty, or sour foods, and foods with acid (oranges and grapefruits), which can irritate the open sore.

Apply a water-based zinc ointment such as Desitin. It helps dry out the sore so it can heal faster.

Extra sleep and plenty of liquids to drink can help.

Adolescents can learn to manage their own outbreaks. They can take the following steps:

Use over-the-counter pain relievers, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil).

Nutritional concerns

If children are prone to recurrent viral infections, parents should review their eating habits. The children should avoid foods and drinks that are proven suppressors of immunity (foods high in sugar, caffeine , and alcohol content) and have regular meals with plenty of fresh vegetables and fruits and whole-grain products. Some foods may be increased or reduced for specific types of viral infections. For herpes, foods containing the amino acid arginine (nuts and seeds) need to be reduced, and those containing the amino acid lysine (yogurt and cottage cheese) need to be increased. Immune system health in children can also benefit from a wide range of vitamins and minerals as nutritional supplements. Vitamin B complex and vitamins A, C, and E are the most important supplements.

Prognosis

Anyone can become infected with the herpes virus. Once infected, the virus remains latent in the body for life. It lives in nerve cells where the immune system cannot find it. The herpes virus lies dormant in the nerves of the face and is reactivated by sunburn, a recent viral illness (cold or flu), and periods of stress. Cold sores spread from person to person by direct skin-to-skin contact.

The highest risk for spreading the virus is the time period beginning with the blisters and ending with scab formation. However, infected people need not have visible blisters to spread the infection since the virus may be present in the saliva without obvious oral lesions.

Most children experience fewer than two recurrent outbreaks of cold sores each year; some have frequent outbreaks and others never experience outbreaks. Most blisters form in the same area each time and are triggered by the same reasons (such as stress, sun exposure, etc.).

Prevention

Cold sores are contagious. As of 2004 there were no herpes vaccines available, although herpes vaccines were in research and development. Avoiding close contact with people shedding the virus is the best way to prevent primary herpes. Several practices can reduce reoccurring cold sores and the spread of virus:

Parents should teach children not to share drinks, food, or eating utensils, and not to exchange kisses with someone with mouth sores.

When parents have an outbreak, they should avoid kissing their children (and other adults).

Parents should be watchful of infected children and not allow them to share toys that may be put into the mouth. Toys that have been in the child's mouth should be disinfected before other children play with them.

Parents should be especially careful with infants; they should not kiss the eyes or lips of a baby who is under six months old. The child's eyes and genitals are particularly susceptible to the herpes virus. They should keep the child from picking at a cold sore as much as possible.

To keep from spreading the infection to other parts of the child's body or giving the virus to someone else, parents and caregivers should wash their hands and the child's hands often, especially after feedings and diaper changes.

The child should be protected from the sun, since exposure to sunlight can trigger an outbreak. If the child is outside on a sunny day, generously apply sunscreen and lip balm that contains sun block before prolonged exposure to the sun. Sun block should be used during both winter and summer months, to help prevent cold cores. Wearing a hat with a large brim is also helpful.

Parents should wear gloves when applying ointment to a child's sore. They should remove gloves and wash hands before and after changing diapers.

Antibiotic ointments may be used to treat secondary bacterial infection of lesions. Parent should avoid using steroid creams or gels on a suspected herpes infection because these agents could make the infection worse.

Parents should maintain good general health. A healthy diet, plenty of sleep, and exercise help to minimize the chance of getting a cold or the flu, which may bring on cold sores. Also, good general health keeps the immune system strong; this helps to keep the virus in check and prevents outbreaks.

Parental concerns

The child with a herpes infection is usually miserable and needs generous cuddling and comfort in spite of the infection. Parents of children who get cold sores should be aware of early symptoms and be ready to treat the sore in the first couple days. They should also keep in mind the prevention tips mentioned above. Parents should call the child's pediatrician if the child has not had a cold sore before, especially in the case of babies.

KEY TERMS

Antiviral drug—A medication that can destroy viruses and help treat illnesses caused by them.

Contagious—The movement of disease between people. All contagious disease is infectious, but not all infections are contagious.

Latent virus—A nonactive virus that is in a dormant state within a cell. The herpes virus is latent in the nervous system.

Oral lesions—A single infected sore in the skin around the mouth or mucus membrane inside of the oral cavity.

Prodrome—Early symptoms that warn of the beginning of disease. For example, the herpes prodrome consists of pain, burning, tingling, or itching at a site before blisters are visible while the migraine prodrome consists of visual disturbances.

Recurrence—The return of an active infection following a period of latency.

Reye's syndrome—A serious, life-threatening illness in children, usually developing after a bout of flu or chickenpox, and often associated with the use of aspirin. Symptoms include uncontrollable vomiting, often with lethargy, memory loss, disorientation, or delirium. Swelling of the brain may cause seizures, coma, and in severe cases, death.

Secretion—A substance, such as saliva or mucus, that is produced and given off by a cell or a gland.

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Cold Sore

Cold sore

Definition

A cold sore is a fluid-filled blister that usually appears at the edge of the lips. Cold sores are caused by a herpes simplex virus infection.

Description

A cold sore is a fluid-filled, painful blister that is usually on or around the lips. Other names for cold sores are fever blisters , oral herpes, labial herpes, herpes labialis, and herpes febrilis. Cold sores most often occur on the lips, distinguishing them from the common canker sore that is usually located inside the mouth. Cold sores do not usually occur inside the mouth except during the initial episode. Canker sores usually form either on the tongue or inside the cheeks.

Cold sores are caused by a herpes virus. There are eight different kinds of human herpes viruses. Only two of these, herpes simplex, types 1 and 2, can cause cold sores. It is commonly believed that herpes simplex virus type 1 infects above the waist and herpes simplex virus type 2 infects below the waist. This is not completely true. Both herpes virus type 1 and type 2 can cause herpes lesions on the lips or genitals but recurrent cold sores are almost always type 1.

Oral herpes is very common. More than 60% of Americans have had a cold sore and almost 25% of those infected experience recurrent outbreaks. Most of these persons became infected before age 10. Anyone can become infected by herpes virus and once infected, the virus remains latent for life. Herpes viruses are spread from person to person by direct skin-to-skin contact. The highest risk for spreading the virus is the time period beginning with the appearance of blisters and ending with scab formation. However, infected persons need not have visible blisters to spread the infection to others since the virus may be present in the saliva without obvious oral lesions.

Viruses are different from bacteria. While bacteria are independent and can reproduce on their own, viruses enter human cells and force them to make more virus. The infected human cell is usually killed and releases thousands of new viruses. The cell death and resulting tissue damage causes the actual cold sores. In addition, herpes virus can infect a cell and instead of making the cell

produce new viruses, it hides inside the cell and waits. Herpes virus hides in the nervous system. This is called "latency." A latent virus can wait inside the nervous system for days, months, or even years. At some future time, the virus "awakens" and causes the cell to produce thousands of new viruses which causes an active infection.

This process of latency and active infection is best understood by considering the cold sore cycle. An active infection is obvious because cold sores are present. The first infection is called the "primary" infection. This active infection is then controlled by the body's immune system and the sores heal. In between active infections the virus is latent. At some point in the future, latent viruses become activated and once again cause sores. These are called "recurrent" infections. Although it is unknown what triggers a latent virus to activate, several conditions seem to bring on infections. These include stress , illness, fatigue , exposure to sunlight, menstruation , fever, and diet.

Causes & symptoms

While anyone can be infected by herpes virus, not everyone will show symptoms. The first symptoms of herpes occur within two to 20 days after contact with an infected person. Symptoms of the primary infection are usually more severe than those of recurrent infections. The primary infection can cause symptoms like other viral infections including fatigue, headache , fever, and swollen lymph nodes in the neck.

Typically, 50–80% of persons with oral herpes experience a prodrome (symptoms of oncoming disease) of pain , burning, itching , or tingling at the site where blisters will form. This prodrome stage may last anywhere from a few hours, to one or two days. The herpes infection prodrome occurs in both the primary infection and recurrent infections.

In 95% of patients with cold sores, the blisters occur at the outer edge of the lips which is called the "vermilion border." Less often, blisters form on the nose, chin, or cheek. Following the prodrome, the disease process is rapid. First, small red bumps appear which quickly form fluid-filled blisters. The painful blisters may either burst and form a scab or dry up and form a scab. Within two days of the first red bumps, all the blisters have formed scabs. The skin heals completely and without scarring within six to 10 days.

Some children have a very serious primary (first episode) herpes infection called gingivostomatitis. This causes fever, swollen lymph glands, and numerous blisters inside the mouth and on the lips and tongue, which may form large, open sores. These painful sores may last up to three weeks and can make eating and drinking difficult. Because of this, young children with gingivostomatitis are at risk for dehydration (excessive loss of water from the body).

Most people experience fewer than two recurrent outbreaks of cold sores each year. Some people never experience outbreaks while others have more frequent occurrences. In most people, the blisters form in the same area each time and are triggered by the same factors (such as stress, sun exposure, etc.).

Diagnosis

Because oral herpes is so common, it is diagnosed primarily by symptoms. It can be diagnosed and treated by the family doctor, dermatologists (doctors who specialize in skin diseases) and infectious disease specialists. Laboratory tests may be performed to look for the virus. Because healing sores do not shed much virus, a sample from an open sore is taken for viral culture. A sterile cotton swab is wiped over open sores and the sample used to infect human cells in culture. Cells which are killed by herpes virus have a certain appearance under microscopic examination. The results of this test are available within two to 10 days.

Oral herpes may resemble a bacterial infection called impetigo . This skin infection is most commonly seen in children and causes herpes-like blisters around the mouth and nose. Also, because oral herpes can occur inside the mouth, the blisters could be mistaken for common canker sores. Therefore, doctors need to determine whether the blisters are oral herpes, canker sores, or impetigo. The diagnosis and treatment of herpes infections should be covered by most insurance providers.

Treatment

There is no cure for cold sores but many alternative treatments can reduce outbreaks and shorten healing time. During an outbreak of cold sores, salty foods, citrus foods (oranges etc.), and other foods that irritate the sores should be avoided. Wash the sores once or twice a day with a warm, saline solution and pat gently to dry. Application of ice or a cold wet teabag for 10 minutes four or five times a day can relieve the itching and burning.

Supplements

Vitamin and mineral supplements and diet may have an effect on the recurrence and duration of cold sores. In general, cold sore sufferers should eat a healthy diet of unprocessed foods such as vegetables, fruits, and whole grains. Alcohol, caffeine , chocolate, nuts, and sugar should be avoided.

An imbalance in the amino acids lysine and arginine is thought to be a contributing factor in herpes virus outbreaks. A diet that is rich in the amino acid lysine may help prevent recurrences of cold sores. Foods that contain high levels of lysine include most vegetables, legumes, fish, turkey, and chicken. In one study, patients taking lysine supplements had milder symptoms during an outbreak, a shorter healing time, and had fewer outbreaks than patients who did not take lysine. Patients should take 1,000 mg of lysine three times a day during a cold sore outbreak and 500 mg daily on an ongoing basis to prevent recurrences. The effectiveness of lysine supplementation in treating herpes infections is controversial. Intake of the amino acid arginine should be reduced. Foods rich in arginine that should be avoided are chocolate, peanuts, almonds, and other nuts and seeds.

Vitamin C and bioflavonoids (a substance in fruits that helps the body to absorb and use vitamin C) have been shown to reduce the duration of a cold sore outbreak and reduce the number of sores. The vitamin B complex includes important vitamins that support the nervous system where herpes viruses are dormant. B complex vitamins also can help manage stress, an important contributing factor to the outbreak of herpes viruses. Some studies have shown that correcting iron , folate, vitamin C, or vitamin B12 deficiencies improves cold sores. Vitamin E speeds healing and reduces pain. Squeeze the oil from a vitamin E capsule onto a cotton ball and apply to the sore for 30 minutes to one hour.

Herbals

Mints are effective antivirals. Lemon balm or Melissa (Melissa officinalis ) is comparable to the antiviral acyclovir in the treatment of cold sores. Apply lemon balm cream to the sore several times a day. Alternatively, prepare lemon balm tea, drink the tea and apply the dregs to the sore for one or two hours. The patient may also drink several strong cups of teas prepared from hyssop , oregano, rosemary, thyme , and sage . Licorice may be added to the tea.

Licorice (Glycyrrhiza glabra ) is an antiviral and immune system stimulant. Licorice is available as a capsule or an ointment. Gradually take up to 300 mg a day. Apply ointment that contains glycyrrhetinic or glycyrrhizic acid directly to the sore as necessary. Ingestion of licorice may cause loose stools and high blood pressure.

Chinese medicine

Treatment with Qing Dai San (Natural Indigo Powder) mixed with cold boiled water and applied to the sore is generally all that is needed. For recurrent cold sores, the following oral preparations can be taken:

Mild electric current. Preliminary studies of a small device that delivers a mild electric current to the cold sore site have shown shorter duration of pain and blisters.

Allopathic treatment

There is no cure for herpes virus infections. There are antiviral drugs available which have some effect in lessening the symptoms and decreasing the length of herpes outbreaks. There is evidence that some may also prevent future outbreaks. These antiviral drugs are most effective when taken as early in the infection process as possible. For the best results, drug treatment should begin during the prodrome stage before blisters are visible.

Acyclovir (Zovirax) has been the drug of choice for herpes infection and can be given intravenously or taken by mouth. It can be applied directly to sores as an ointment but is not very useful in this form. A liquid form for children is also available. Acyclovir is effective in treating both the primary infection and recurrent outbreaks. When taken by mouth to prevent an outbreak, acyclovir reduces the frequency of herpes outbreaks. In 2001, a report showed that use of high-dose acyclovir during primary infection will reduce the extent of latent infection. The use of penciclovir (Denavir) cream as soon as the prodrome symptoms appear speeds healing.

Over-the-counter lip products which contain the chemical phenol (such as Blistex Medicated Lip Ointment) and numbing ointments (Anbesol) help to relieve cold sores. Pharmacists also recommend the over-thecounter medicine Abreva, the only cold sore medicine approved by the U.S. Food and Drug Administration (FDA) to shorten healing time. Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) may be taken if necessary to reduce pain and fever.

Expected results

Oral herpes can be painful and embarrassing but it is not a serious infection. There is no cure for oral herpes but outbreaks usually occur less frequently after age 35. Alternative medicines can reduce the pain, prevent outbreaks, and shorten the course of cold sores. The spread of herpes virus to the eyes is very serious. Herpes virus can infect the cells in the cornea and cause scarring that may impair vision.

Prevention

The only way to prevent oral herpes is to avoid contact with infected persons. This is not an easy solution because many people are not aware that they are infected and can easily infect others. As of 2001 there were no known herpes vaccines available, although vaccines are being tested.

Several practices can reduce the occurrence of cold sores and the spread of virus to other body locations or people. These practices are:

Avoidance of sun exposure to the face. Before getting prolonged exposure to the sun, apply sunscreen to the face and especially to the lips. Wearing a hat with a large brim is also helpful.

Avoid touching cold sores. Squeezing, picking, or pinching blisters can allow the virus to spread to other parts of the lips or face and infect those sites.

Wash hands frequently. Persons with oral herpes should wash their hands carefully before touching others. An infected person can spread the virus to others even when he or she has no obvious blisters.

Avoid contact with others during active infection. Infected persons should avoid kissing or sexual contact with others until after the cold sores have healed.

Wear gloves when applying ointment to a child's sore.

Be especially careful with infants. Never kiss the eyes or lips of a baby who is under six months old.

Be watchful of infected children. Do not allow infected children to share toys that may be put into the mouth. Toys that have been mouthed should be disinfected before other children play with them.

Maintain good general health. A healthy diet, plenty of sleep, and exercise help to minimize the chance of getting a cold or the flu, which are known to bring on cold sores. Also, good general health keeps the immune system strong which helps to keep the virus in check and prevent outbreaks.

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Within the “Cite this article” tool, pick a style to see how all available information looks when formatted according to that style. Then, copy and paste the text into your bibliography or works cited list.

Because each style has its own formatting nuances that evolve over time and not all information is available for every reference entry or article, Encyclopedia.com cannot guarantee each citation it generates. Therefore, it’s best to use Encyclopedia.com citations as a starting point before checking the style against your school or publication’s requirements and the most-recent information available at these sites:

Modern Language Association

The Chicago Manual of Style

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Notes:

Most online reference entries and articles do not have page numbers. Therefore, that information is unavailable for most Encyclopedia.com content. However, the date of retrieval is often important. Refer to each style’s convention regarding the best way to format page numbers and retrieval dates.

In addition to the MLA, Chicago, and APA styles, your school, university, publication, or institution may have its own requirements for citations. Therefore, be sure to refer to those guidelines when editing your bibliography or works cited list.

Cold Sore

Cold Sore

Definition

A cold sore is a fluid-filled blister which usually appears at the edge of the lips. Cold sores are caused by a herpes simplex virus infection.

Description

A cold sore is a fluid-filled, painful blister that is usually on or around the lips. Other names for a cold sore are fever blister, oral herpes, labial herpes, herpes labialis, and herpes febrilis. Cold sores most often occur on the lips which distinguishes them from the common canker sore which is usually inside the mouth. Cold sores do not usually occur inside the mouth except during the initial episode. Canker sores usually form either on the tongue or inside the cheeks.

Cold sores are caused by a herpes virus. There are eight different kinds of human herpes viruses. Only two of these, herpes simplex types 1 and 2, can cause cold sores. It is commonly believed that herpes simplex virus type 1 infects above the waist and herpes simplex virus type 2 infects below the waist. This is not completely true. Both herpes virus type 1 and type 2 can cause herpes lesions on the lips or genitals, but recurrent cold sores are almost always type 1.

Oral herpes is very common. More than 60% of Americans have had a cold sore, and almost 25% of those infected experience recurrent outbreaks. Most of these persons became infected before age 10. Anyone can become infected by herpes virus and, once infected, the virus remains latent for life. Herpes viruses are spread from person to person by direct skin-to-skin contact. The highest risk for spreading the virus is the time period beginning with the appearance of blisters and ending with scab formation. However, infected persons need not have visible blisters to spread the infection to others since the virus may be present in the saliva without obvious oral lesions.

Viruses are different from bacteria. While bacteria are independent and can reproduce on their own, viruses enter human cells and force them to make more virus. The infected human cell is usually killed and releases thousands of new viruses. The cell death and resulting tissue damage causes the actual cold sores. In addition, the herpes virus can infect a cell and, instead of making the cell produce new viruses, it hides inside the cell and waits. The herpes virus hides in the nervous system. This is called "latency." A latent virus can wait inside the nervous system for days, months, or even years. At some future time, the virus "awakens" and causes the cell to produce thou sands of new viruses that cause an active infection.

This process of latency and active infection is best understood by considering the cold sore cycle. An active infection is obvious because cold sores are pre sent. The first infection is called the "primary" infection. This active infection is then controlled by the body's immune system and the sores heal. In between active infections, the virus is latent. At some point in the future, latent viruses become activated and once again cause sores. These are called "recurrent" infections. Although it is unknown what triggers latent virus to activate, several conditions seem to bring on infections. These include stress, illness, tiredness, exposure to sunlight, menstruation, fever, and diet.

Causes and symptoms

While anyone can be infected by herpes virus, not everyone will show symptoms. The first symptoms of herpes occur within two to 20 days after contact with an infected person. Symptoms of the primary infection are usually more severe than those of recurrent infections. The primary infection can cause symptoms like other viral infections including tiredness, headache, fever, and swollen lymph nodes in the neck.

Typically, 50 to 80% of persons with oral herpes experience a prodrome (symptoms of oncoming disease) of pain, burning, itching, or tingling at the site where blisters will form. This prodrome stage may last anywhere from a few hours to one to two days. The herpes infection prodrome occurs in both the primary infection and recurrent infections.

In 95% of the patients with cold sores, the blisters occur at the outer edge of the lips which is called the "vermilion border." Less often, blisters form on the nose, chin, or cheek. Following the prodrome, the disease process is rapid. First, small red bumps appear that quickly form fluid-filled blisters. The painful blisters may either burst and form a scab or dry up and form a scab. Within two days of the first red bumps, all the blisters have formed scabs. The skin heals completely and without scarring within six to ten days.

Some children have a very serious primary (first episode) herpes infection called "gingivostomatitis." This causes fever, swollen lymph glands, and numerous blisters inside the mouth and on the lips and tongue that may form large, open sores. These painful sores may last up to three weeks and can make eating and drinking difficult. Because of this, young children with gingivostomatitis are at risk for dehydration (excessive loss of water from the body).

Most people experience fewer than two recurrent outbreaks of cold sores each year. Some people never experience outbreaks, while some have very frequent outbreaks. In most people, the blisters form in the same area each time and are triggered by the same factors (such as stress, sun exposure, etc).

Diagnosis

Because oral herpes is so common, it is diagnosed primarily by symptoms. It can be diagnosed and treated by the family doctor, dermatologists (doctors who specialize in skin diseases) and infectious disease specialists. Laboratory tests may be performed to look for the virus. Because healing sores do not shed much virus, a sample from an open sore would be taken for viral culture. A sterile cotton swab would be wiped over open sores and the sample used to infect human cells in culture. Cells that are killed by the herpes virus have a certain appearance under microscopic examination. The results of this test are available within two to 10 days.

Oral herpes may resemble a bacterial infection called impetigo. This skin infection is most commonly seen in children and causes herpes-like blisters around the mouth and nose. Also, because oral herpes can occur inside the mouth, the blisters could be mistaken for common canker sores. Therefore, the doctor would need to determine whether the blisters are oral herpes, canker sores, or impetigo. The diagnosis and treatment of herpes infections should be covered by most insurance providers.

Treatment

There is no cure for herpes virus infections. There are antiviral drugs available that have some effect on lessening the symptoms and decreasing the length of herpes outbreaks. There is evidence that some may also prevent future outbreaks. These antiviral drugs work by interfering with the replication of the viruses, and are most effective when taken as early in the infection process as possible. For the best results, drug treatment should begin during the prodrome stage before blisters are visible. Depending on the length of the outbreak, drug treatment could continue for up to 10 days.

Acyclovir (Zovirax) is the drug of choice for herpes infection and can be given intravenously or taken by mouth. It can be applied directly to sores as an ointment, but is not very useful in this form. A liquid form for children is also available. Acyclovir is effective in treating both the primary infection and recurrent outbreaks. When taken by mouth to prevent an outbreak, acyclovir reduces the frequency of herpes outbreaks.

During an outbreak of cold sores, salty foods, citrus foods (oranges etc.), and other foods that irritate the sores should be avoided. Wash the sores once or twice a day with warm, soapy water and pat gently to dry. Over-the-counter lip products that contain the chemical phenol (such as Blistex Medicated Lip Ointment) and numbing ointments (Anbesol) help to relieve cold sores. A bandage may be placed over the sores to protect them and prevent spreading the virus to other sites on the lips or face. Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) may be taken if necessary to reduce pain and fever.

Alternative treatment

Vitamin and mineral supplements and diet may have an effect on the recurrence and duration of cold sores. In general, cold sore sufferers should eat a healthy diet of unprocessed foods such as vegetables, fruits, and whole grains. Alcohol, caffeine, and sugar should be avoided.

An imbalance in the amino acids lysine and arginine is thought to be one contributing factor in herpes virus outbreaks. A diet that is rich in the amino acid lysine may help prevent recurrences of cold sores. Foods which contain high levels of lysine include most vegetables, legumes, fish, turkey, and chicken. In one study, patients taking lysine supplements had milder symptoms during an outbreak, a shorter healing time, and had fewer outbreaks than patients who did not take lysine. Patients should take 1,000 mg of lysine three times a day during a cold sore outbreak and 500 mg daily on an ongoing basis to prevent recurrences. Intake of the amino acid arginine should be reduced. Foods rich in arginine that should be avoided are chocolate, peanuts, almonds, and other nuts and seeds.

Vitamin C and bioflavonoids (a substance in fruits that helps the body to absorb and use vitamin C) have been shown to reduce the duration of a cold sore outbreak and reduce the number of sores. The vitamin B complex includes important vitamins that support the nervous system where viruses can hide out. B complex vitamins can also help manage stress, an important contributing factor to the outbreak of herpes viruses. Applying the oil in vitamin E capsules directly to cold sores may provide relief. Zinc lozenges appear to affect the reproduction of viruses and also enhance the immune system. Ointments containing lemon balm (Melissa officinalis ) or licorice (Glycyrrhiza glabra ) and peppermint (Mentha piperita ) have been shown to help cold sores heal.

Prognosis

Oral herpes can be painful and embarrassing but, it is not a serious infection. There is no cure for oral herpes, but outbreaks usually occur less frequently after age 35. The spread of the herpes virus to the eyes is very serious. The herpes virus can infect the cells in the cornea and cause scarring that may impair vision.

Prevention

The only way to prevent oral herpes is to avoid contact with infected persons. This is not an easy solution because many people are not aware that they are infected and can easily infect others. Currently there are no herpes vaccines available, although herpes vaccines are being tested.

Several practices can reduce the occurrence of cold sores and the spread of virus to other body locations or people. These practices are:

Avoidance of sun exposure to the face. Before getting prolonged exposure to the sun, apply sunscreen to the face and especially to the lips. Wearing a hat with a large brim is also helpful.

Avoid touching cold sores. Squeezing, picking, or pinching blisters can allow the virus to spread to other parts of the lips or face and infect those sites.

Wash hands frequently. Persons with oral herpes should wash their hands carefully before touching others. An infected person can spread the virus to others even when he or she has no obvious blisters.

Avoid contact with others during active infection. Infected persons should avoid kissing or sexual contact with others until after the cold sores have healed.

Wear gloves when applying ointment to a child's sore.

Be especially careful with infants. Never kiss the eyes or lips of a baby who is under six months old.

Be watchful of infected children. Do not allow infected children to share toys that may be put into the mouth. Toys that have been mouthed should be disinfected before other children play with them.

Maintain good general health. A healthy diet, plenty of sleep, and exercise help to minimize the chance of getting a cold or the flu, which are known to bring on cold sores. Also, good general health keeps the immune system strong; this helps to keep the virus in check and prevents outbreaks.

KEY TERMS

Latent— A nonactive virus which is in a dormant state within a cell. The herpes virus is latent in the nervous system.

Prodrome— Symptoms that warn of the beginning of disease. The herpes prodrome consists of pain, burning, tingling, or itching at a site before blisters are visible.

Recurrence— The return of an active infection following a period of latency.

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In addition to the MLA, Chicago, and APA styles, your school, university, publication, or institution may have its own requirements for citations. Therefore, be sure to refer to those guidelines when editing your bibliography or works cited list.

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Within the “Cite this article” tool, pick a style to see how all available information looks when formatted according to that style. Then, copy and paste the text into your bibliography or works cited list.

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Cold Sore

Cold Sore

Definition

A cold sore is a clear, fluid-filled blister, which often appears on the lips or nose. Cold sores, also referred to as fever blisters, are caused by a viral infection, herpes simplex virus Type 1 (HSV-1).

Description

Cold sores are painful, unsightly, and often recurrent. HSV-1 often occurs on the lower face but can occur on the genitals or buttocks. Though rarely fatal, HSV-1 can be serious if cold sores occur in newborns, the chronically ill, or the elderly.

Other names for cold sores are oral herpes, labial herpes, herpes labialis, and herpes febrilis. They are different from common canker sores because they usually are on the lips, whereas canker sores usually occur inside the mouth, on the tongue, or inside the cheeks. Cold sores rarely occur inside the mouth except during the initial episode.

While there are eight types of herpes viruses, cold sores are only caused by HSV-1 or herpes simplex virus Type 2 (HSV-2). It is commonly believed that herpes simplex virus type 1 infects above the waist and herpes simplex virus type 2 infects below the waist. This is not completely true. HSV-1 does appear on the genitals and sometimes on other areas of the body. Nurses and other health care workers have been known to get herpetic sores after the virus has entered a break in the skin of their fingers.

Oral herpes is very common. About 50-80% (some estimates are as high as 90%) of Americans are thought to carry antibodies for HSV-1. Most people who are exposed to HSV-1 become infected but only 10% of those people have symptoms, such as sores, and experience recurring outbreaks of the infection. Of the 50 million Americans thought to be infected with HSV-1, most acquired the virus when they were children and only about 5% are bothered enough by HSV-1 to consider it a medical problem.

Anyone can become infected by the herpes virus, and once a person is infected the virus remains latent for life. Herpes viruses are spread from person to person by direct skin-to-skin contact and, sometimes, by respiratory transmission (coughing or sneezing). The highest risk for spreading the virus is the time period beginning with the appearance of blisters and ending with scab formation. However, infected persons need not have visible blisters to spread the infection to others, since the virus may be present in the saliva without obvious oral lesions.

Viruses are different from bacteria. While bacteria are independent and can reproduce on their own, viruses enter human cells and force the cells to make more of the virus. The infected human cell is usually killed and releases thousands of new viruses. The cell death and resulting tissue damage causes the actual cold sores. In addition, the herpes virus can infect a cell and instead of making the cell produce new viruses, it hides inside the cells of the nervous system. This is called "latency." A latent virus can wait inside the nervous system for days, months, or even years. At some future time, the virus "awakens" and causes the cell to produce thousands of new viruses which cause an active infection.

This process of latency and active infection is best understood by considering the cold sore cycle. An active infection is obvious because cold sores are present. The first infection is called the "primary" infection. This active infection is then controlled by the body's immune system and the sores heal. In between active infections the virus is latent. At some point in the future, latent viruses become activated and once again cause sores. These are called "recurrent" infections. Although it is not known what triggers the latent virus to activate, several conditions seem to bring on infections. These include stress, illness, tiredness, exposure to sunlight, menstruation, fever, and diet.

Causes and symptoms

While anyone can be infected by the herpes virus, not everyone will show symptoms. The first symptoms of herpes occur within two to 20 days after contact with an infected person. Symptoms of the primary infection are usually more severe than those of recurrent infections. The primary infection can cause symptoms like other viral infections, including tiredness, headache, fever, and swollen lymph nodes in the neck.

People who experience outbreaks might have one or several blisters. Typically, 50-80% of persons who have outbreaks experience prodrome symptoms of oncoming disease of pain, burning, itching, or tingling at the site where blisters will form. This prodrome stage may last from a few hours, to one or two days. The herpes infection prodrome occurs in both the primary infection and recurrent infections.

In 95% of people with cold sores, the blisters occur at the outer edge of the lips, which is called the "vermilion border." Less often, blisters form on the nose, chin, or cheek. Following the prodrome, the disease process is rapid. First, small red bumps appear which quickly form fluid-filled blisters. The painful blisters may either burst and form a scab or dry up and form a scab. Within two days of the first red bumps, all the blisters have formed scabs. The skin heals completely and without scarring within six to ten days. The virus then moves to nerve cells and remains in its resting state until the next outbreak, which can occur in the same or a nearby site.

Some children have a very serious primary (first episode) herpes infection called "gingivostomatitis." This causes fever, swollen lymph glands, and numerous blisters inside the mouth, lips, and tongue that may form large, open sores. These painful sores may last up to three weeks and can make eating and drinking difficult. Because of this, young children with gingivostomatitis are at risk from dehydration (excessive loss of water from the body).

Most people experience fewer than two recurrent outbreaks of cold sores each year. Some people never experience outbreaks, while some have very frequent outbreaks, as often as every few weeks. In most people, the blisters form in the same area each time and are triggered by the same factors (such as stress, sun exposure, etc.).

Diagnosis

The typical appearance of HSV-1 often makes it an easy visual diagnosis. Health care professionals who are uncertain of the diagnosis can swab the infected area and send it to a lab for analysis. HSV-1 can be diagnosed and treated by family doctors, dermatologists (doctors who specialize in skin diseases), and infectious disease specialists. Sometimes, dentists or nurses are the first to see the signs of HSV-1. Other laboratory tests, including scrapings and blood tests, might be performed to look for the virus. These tests produce valid results only in the early stages of an outbreak and, sometimes, more than one test is needed.

Oral herpes may resemble a bacterial infection called "impetigo." This skin infection is most commonly seen in children and causes herpes-like blisters around the mouth and nose. Also, because oral herpes can occur inside the mouth, the blisters could be mistaken for common canker sores. Therefore, the doctor would need to determine whether the blisters are oral herpes, canker sores, or impetigo. The diagnosis and treatment of herpes infections should be covered by most insurance providers.

Treatment

There is no cure for herpes virus infections. There are antiviral drugs available, which have some effect in lessening the symptoms and decreasing the length of herpes outbreaks. There is evidence that some may also prevent future outbreaks. These antiviral drugs work by interfering with the replication of the viruses and are most effective when taken as early in the infection process as possible. For the best results, drug treatment should begin during the prodrome stage before blisters are visible. Depending on the length of the outbreak, drug treatment could continue for up to ten days or be used on an on-going basis as a method of prevention.

Acyclovir, famciclovir, and valcyclovir are oral antiviral medications developed to effectively treat herpes infections. In June 2000, the United StatesFood and Drug Administration approved the first over-the-counter ointment, called docosanol 10%, as a topical treatment for cold sores.

During an outbreak of cold sores, salty foods, citrus fruits (oranges, etc.), and other foods which irritate the sores should be avoided. The sores should be washed once or twice a day with warm, soapy water and patted gently dry. Over-the-counter lip products that contain the chemical phenol (such as Blistex Medicated Lip Ointment) and numbing ointments (Anbesol) help to relieve cold sores. Sometimes applying ice at the first sign of a cold sore diminishes the outbreak. A band-aid may be placed over the sores to protect them and prevent spreading the virus to other sites on the lips or face. Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) may be taken if necessary to reduce pain and fever.

Alternative treatment

Vitamin and mineral supplements and diet may have an effect on the recurrence and duration of cold sores. In general, cold sore sufferers should eat a healthy diet of unprocessed foods such as vegetables, fruits, and whole grains. Alcohol, caffeine, and sugar should be avoided.

An imbalance in the amino acids lysine and arginine is thought to be one contributing factor in herpes virus outbreaks. A diet that is rich in the amino acid lysine may help prevent recurrence of cold sores. Foods which contain high levels of lysine include most vegetables, legumes, fish, turkey, and chicken. In one study, patients taking lysine supplements had milder symptoms during an outbreak, a faster healing time, and had fewer outbreaks than patients who did not take lysine. Patients should take 1,000 mg of lysine three times a day during a cold sore outbreak and 500 mg daily on an ongoing basis to prevent recurrences. Intake of the amino acid arginine should be reduced. Foods rich in arginine that should be avoided are chocolate, peanuts, almonds, and other nuts and seeds.

Vitamin C and bioflavonoids (a substance in fruits that helps the body to absorb and use vitamin C), have been shown to reduce the duration of a coldsore outbreak and reduce the number of sores. The vitamin B complex includes important vitamins that support the nervous system where viruses can hide out. B complex vitamins also can help manage stress, an important contributing factor to the outbreak of herpes viruses. Applying the oil in vitamin E capsules directly to cold sores may provide relief. Zinc lozenges appear to affect the reproduction of viruses and also enhance the immune system. Ointments containing lemon balm (Melissa officinalis) or licorice (Glycyrrhiza glabra) and peppermint (Menthapiperita) have been shown to help cold sores heal.

Prognosis

Oral herpes can be painful and embarrassing but it is not a serious condition. There is no cure for oral herpes but outbreaks usually occur less frequently with time. The spread of the herpes virus to the eyes is very serious. Herpes virus can infect the cells in the cornea and cause scarring which may impair vision. Those who are seriously ill, with compromised immune systems, are vulnerable to more severe and dangerous outbreaks.

Health care team roles

Registered nurses are often involved in helping to identify oral herpes. It is important that nurses then educate patients that cold sores caused by herpes simplex are highly contagious. Nurses need to teach patients not to touch their mouths and then other parts of their bodies, such as the eyes, because they can spread the virus to other parts of their bodies. Nurses should also inform patients that if the sore is indeed herpetic, patients might experience intense symptoms when the infection first appears and the sores and symptoms could last up to two weeks. Normally, subsequent outbreaks, if they occur, are shorter because people generally build up some immunity to the virus. Nurses should let patients know about factors, such as sun exposure, that can stimulate outbreaks, and educate them about over-the-counter and prescription options. They can let patients know what they can do to alleviate their symptoms, such as applying ice at the first signs of an outbreak. While RNs educate patients about cold sores, nurse practitioners often diagnose and treat them just as a physician would.

Nurses can direct patients to many sites on the Internet that can help to answer their questions. For example, the American Academy of Dermatology at www.aad.org, www.herpes.org and www.herpeszone.com. The Herpes Resource Center, a public service of the American Social Health Association, provides educational pamphlets and a counseling line at 919-361-8488.

Prevention

The only way to prevent oral herpes is to avoid contact with those who are infected. This is not an easy solution because as many as 60% of those who are infected do not realize or admit that they may have herpes. As of 2001, there are no herpes vaccines available, although herpes vaccines, which will function to prevent infection in new patients, are being tested. The belief is that an effective vaccine is about three to five years away. Researchers are also attempting to reduce the rate of asymptomatic viral shedding to prevent transmission of the virus. Many say that a cure for herpes will not come for another seven to 10 years.

Several practices can reduce the occurrence of cold sores and the spread of virus to other body locations or people. These practices are:

Avoidance of sun exposure to the face. Before getting prolonged exposure to the sun, apply sunscreen to the face and especially to the lips. Wearing a hat with a large brim is also helpful.

Avoid touching cold sores. Squeezing, picking, or pinching blisters can allow the virus to spread to other parts of the lips or face, and infect those sites.

Herpes can be transmitted via respiratory secretions, such as coughing or sneezing, so avoiding these situations is advised.

Washing hands frequently. Persons with oral herpes should wash their hands carefully before touching others. An infected person can spread the virus to others, even when he or she has no obvious blisters.

Avoid contact with others during active infection. Infected persons should avoid kissing and sexual contact with others until after the cold sores have healed.

Wear gloves when applying ointment to a child's sore.

Be especially careful with infants. Never kiss the eyes or lips of a baby who is under six months old.

Be watchful of infected children. Do not allow infected children to share toys that may be put into the mouth. Toys that have been mouthed should be disinfected before other children play with them.

Maintain good general health. A healthy diet, plenty of sleep, and exercise help to minimize the chance of getting a cold or the flu, which are known to bring on cold sores. Also, good general health keeps the immune system strong, which helps to keep the virus in check and prevents outbreaks.

KEY TERMS

Latent— A non-active virus that is in a dormant state within a cell. Herpes virus is latent in the nervous system.

Prodrome— Symptoms that warn of the beginning of disease. The herpes prodrome consists of pain, burning, tingling, or itching at a site before blisters are visible.

Recurrence— The return of an active infection following a period of latency.

Citation styles

Encyclopedia.com gives you the ability to cite reference entries and articles according to common styles from the Modern Language Association (MLA), The Chicago Manual of Style, and the American Psychological Association (APA).

Within the “Cite this article” tool, pick a style to see how all available information looks when formatted according to that style. Then, copy and paste the text into your bibliography or works cited list.

Because each style has its own formatting nuances that evolve over time and not all information is available for every reference entry or article, Encyclopedia.com cannot guarantee each citation it generates. Therefore, it’s best to use Encyclopedia.com citations as a starting point before checking the style against your school or publication’s requirements and the most-recent information available at these sites:

Modern Language Association

The Chicago Manual of Style

American Psychological Association

Notes:

Most online reference entries and articles do not have page numbers. Therefore, that information is unavailable for most Encyclopedia.com content. However, the date of retrieval is often important. Refer to each style’s convention regarding the best way to format page numbers and retrieval dates.

In addition to the MLA, Chicago, and APA styles, your school, university, publication, or institution may have its own requirements for citations. Therefore, be sure to refer to those guidelines when editing your bibliography or works cited list.